Thought Paper – Developing an Intervention

Thought paper: What I Would Have Done Differently for the National Response of COVID-19

Sierra Teegarden

York College Physician Assistant Program

Public Health: HPPA 516 H-WEB

Dr. Roger Deo

June 20, 2021

When reflecting on the outbreak and spread of the COVID-19 pandemic we can cite various pitfalls in the national response due to lack of preparedness, action, and knowledge. Consequently, many lives were lost and are still dealing with the long-lasting side effects and socioeconomic ramifications of it. To date, there have been over 33.8 million cases and 606,000 deaths from the virus. While the exact long-term effects are not yet known, medical conditions like chronic fatigue syndrome, anosmia, and lung problems amongst other conditions are being reported. To help mitigate the effects of COVID-19, I would have implemented a universal mask mandate sooner while concomitantly revamping the Strategic National Stockpile’s (SNS) mask & N95 respirator supply.

By implementing a universal mask mandate at the onset of the pandemic, we could have avoided the initial interim guidance on mask wearing by the World Health Organization (WHO) that contradicts advice given by health authorities today. On January 29, 2020, WHO posted guidelines stating “a medical mask is not required, as no evidence is available on its usefulness to protect non-sick persons. However, masks might be worn in some countries according to local cultural habits”. This outdated statement is still being cited today by anti-mask movements who make claims such as mask-wearing being is a government conspiracy, infringement on their individual rights, and/or contrary to medical advice. By stating that masks are worn for cultural habits rather than for public health safety, WHO unintentionally may have sparked the ideology that American culture does not subscribe to mask wearing and therefore, should heed future public health instructions on doing so. Public Health in the United States has long faced the challenge of overcoming the ideology of “market justice” which diminishes obligation to the common welfare of the population, increases individual responsibility, and outlines the “fundamental freedom to all individuals to be left alone” (Schneider, 2017). The initial message that masks do not need to be worn may have furthered the market justice ideology by providing a reference that affirms an individual’s choice not to do so. Furthermore, there is controversy surrounding “the extent to which government can and should restrict individual freedom for the purpose of improving the community’s health” (Schneider, 2017). By sending mixed messaging based on the evolving guidelines, it may have furthered distrust of the government, pushing individuals who were once on the fence about this topic to the side of choosing not to wear masks as a political statement of exerting their individual liberty. Clear, consistent messaging could have strengthened public relations to view the health mandate as a rational safety precaution in the best interest of everybody rather than being perceived as a political debate by certain individuals.

The publication goes on further to say, “wearing medical masks when not indicated may cause unnecessary costs, procurement burden and create a false sense of security that can lead to neglecting other essential measures such as hand hygiene practices.” This advice was given based on the initial belief that the virus was spread by larger droplets rather than smaller aerosols making mask wearing less effective. What we now know is that while hand washing remains an important hygienic practice to slow the spread – mask wearing is an essential preventative measure in both the spread and contraction of the virus. Much like the concept of herd immunity for vaccinations, the more people in a community that wear a mask, the larger the benefit to each individual member is (Brooks & Butler, 2021).

It was not until April 3, 2020, that the CDC, in conjunction with the guidance of WHO, issued a statement to the public recommending mask use by the public (Gostin et al., 2020). This advice comes nearly 2.5 months after the first reported COVID-19 case in the United States which took place on January 19, 2020 (Holshue et al., 2020). Given the high level of contagion, the initial lack of respiratory protection undoubtedly exacerbated the number of infections and death toll. While the earliest guidance was likely aimed at conserving masks for health care workers in the wake of a PPE shortage (in addition to the belief that it had little efficacy in community prevention), the outcome points to having created a much larger strain on these workers by the sheer volume of patients being admitted due to the faulty guidelines.

When the recommendation of day-to-day mask wearing was first announced, the public’s confusion was further confounded by the lack of guidance on the different materials to choose from. While it may have been impossible to know the effectiveness of homemade cloth masks at the time due to evolving evidence, the national response should have placed emphasis on encouraging the use and distribution of N95 respirators based on the pre-existing evidence of its efficacy against small particles. N95 respirators are still not currently recommended for general use by the public, despite proving superiority to any other material to date, due to a limited supply which must be reserved for front line workers. Although the Department of Health and Human Services’ Strategic National Stockpile was created to prevent situations like this, its inventory was not sufficient to meet demand (Livingston et al., 2020). The purpose of the SNS is to supplement state and local supplies during public health emergencies such as this. If the SNS would have had adequate stores of N95 respirators to meet the demands of health care workers and the public, the spread could have been further reduced in comparison to using less effective surgical masks, cloth masks, bandanas, or other materials. Surgical masks should have also been stockpiled for those who have medical indications that contraindicate the use of an N95 but may allow for a more breathable material. The goal is to provide the highest level of respiratory protection for every individual for both their own safety and the safety of those who’s mask use is contraindicated. While wearing an N95 might seem unnecessary when waying out certain individual’s risks vs benefits, it would ensure greater protection for those unable to wear masks due to medical indications such as children under 5 years of age or people with certain medical conditions.

The first step in revamping the SNS respirator & surgical mask supply would have been to replenish those used in earlier disasters before resources became scarce in 2020. Masks, along with other pandemic supplies, were under-replenished since their use for the H1N1 pandemic in 2009 (Mathews & Fragos, 2020). The second step would be to increase existing supplies to meet the demands of the United States population rather than the prior emphasis on health care workers and patients alone. The goal is not to have the entirety of the respiratory supply come from this stockpile, but rather to ensure adequate coverage until supply chains can reach the demands of the pandemic. While certain high-grade cotton masks have now shown to be more effective than surgical masks, this data was unknown at the time which would have prevented this type of equipment from being stockpiled. Additionally, because many of these masks are being manufactured by small businesses without quality controls, it is difficult for the public to distinguish which cloth masks meet the standards of the top-tier ones being cited as more effective. Because of these issues, having free and accessible medical grade masks handed out from the SNS would have been the best course of action for promoting proper mask wearing during the mandate.

There are numerous preventative measures and interventions that could have been implemented to slow the initial spread and severity of the COVID-19 pandemic. Creating a universal mask mandate at the onset of the pandemic along with a uniform message on the importance of such a mandate could have alleviated the mistrust and confusion seen today amongst certain groups in the population. The public would have also reaped the benefits of this practice 2.5 months sooner, thus leading to decreased morbidity and mortality. To have successfully put these measures into practice at that time, a sufficient stockpile of medical grade masks and N95 respirators, with a distribution strategy, would have been essential. While these recommendations alone are predicted to have led to decreased transmission rates, they work best when combined with other pandemic preparedness modifications to create a synergistic effect of a slowed pandemic with better health outcomes.

Work Cited

Brooks JT, Butler JC. Effectiveness of Mask Wearing to Control Community Spread of SARS-CoV-2. JAMA. 2021;325(10):998–999. doi:10.1001/jama.2021.1505

Gostin LO, Cohen IG, Koplan JP. Universal Masking in the United States: The Role of Mandates, Health Education, and the CDC. JAMA. 2020;324(9):837–838. doi:10.1001/jama.2020.15271

Holshue, M. L., DeBolt, C., Lindquist, S., Lofy, K. H., Wiesman, J., Bruce, H., Spitters, C., Ericson, K., Wilkerson, S., Tural, A., Diaz, G., Cohn, A., Fox, L. A., Patel, A., Gerber, S. I., Kim, L., Tong, S., Lu, X., Lindstrom, S., … Pillai, S. K. (2020). First Case of 2019 Novel Coronavirus in the United States. New England Journal of Medicine, 382(10), 929–936.

Livingston E, Desai A, Berkwits M. Sourcing Personal Protective Equipment During the COVID-19 Pandemic. JAMA. 2020;323(19):1912–1914. doi:10.1001/jama.2020.5317

Mathews Burwell, S., & Fragos Townsend, F. (2020). The U.S. Must Learn From COVID-19 to Prevent the Next Disaster. Council on Foreign Relations.

Schneider, Mary‐Jane. (2017). Introduction to Public Health (5th ed.). Sudbury, Massachusetts: Jones and Bartlett Publishers, LLC. ISBN – 978-1-284-08923-3

World Health Organization. (2020). Advice on the use of masks in the community, during home care and in health care settings in the context of the novel coronavirus (2019-nCoV) outbreak: Interim guidance, 29 January 2020. World Health Organization. License: CC BY-NC-SA 3.0 IGO